随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！POMR(Problem-OrientedMedicalRecords)表格式住院病历Biographicaldata:一般项目：NameAgeSexMaritalstatusNativityRace姓名年龄性别婚否籍贯民族OccupationDateofadmissionInformantHistory职业入院日期病史叙述者病史Chiefcomplaint主诉Historyofpresentillness现病史Pasthistory既往史：Previoushealthstatus:wellordinarybadInfectiousdiseases平素健康状况：良好一般较差传染病史ImmunizationsAllergies:NYclinicalmanifestation预防接种史过敏史无有临床表现allergen:Trauma:Surgery:过敏原外伤史手术史Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpostive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过)Respiratorysystem:呼吸系统Sorethroatchroniccoughsputumhemoptysiswheezing咽痛慢性咳嗽咳痰咯血哮喘dyspneachestpain呼吸困难胸痛cadiovascularsystem:循环系统Palpitationdyspneaonexertionhemoptysissyncope心悸活动后气促咯血晕厥edemaoflowerlimbsprecordialpainhypertention下肢水肿心前区疼痛高血压Digestivesystem:消化系统Anorexiasourregurgitationbelchingnauseavomitting食欲减退反酸嗳气恶心呕吐abdominaldistentionabdominalpainconstipationdiarrhea腹胀腹痛便秘腹泻hematemesismelenahematocheziajaundice呕血黑便便血黄疸Urinarysystem:泌尿系统Lumbagofrequentmicturitionurgentmicturitionurodynia腰痛尿频尿急尿痛dysuriahematurianocturiapolyuriaoliguriafacialedema排尿困难血尿夜尿多尿少尿面部水肿Hematopoieticsystem造血系统Fatiguedizzinessblurredvisiongingivalbleedig乏力头昏牙龈出血subcutaneoushemorrhageostealgiaepistaxis皮下出血骨痛鼻衄Metabolicandendocrinesystem:代谢及内分泌系统Excessiveappetiteanorexiasweatscoldintolerance食欲亢进食欲减退多汗畏寒polydipsiatremorhandschangeofcharacterobviousobesity多饮双手震颤性格改变显著肥胖emaciationhirsutismhairlosingpigmentation消瘦多毛毛发脱落色素沉着changofsexualfunctionamenorrhea性功能改变闭经Musculoskeletalsystem肌肉骨骼系统Floatingarthralgiaarthraligaswellingofjoints游走性关节痛关节痛关节红肿deformiteiesofjiontsmyalgiaatrophyofmuscle关节变形肌肉痛肌肉萎缩Nervoussystem神经系统Dizzinessheadachevertigosyncopedegenerationofmemory头昏头痛眩晕晕厥记忆力减退visualdisturbanceinsomniadisturbanceofconsciousness视力障碍失眠意识障碍tremorspasmparalysisparesthesia颤动抽搐瘫痪感觉异常Personalhistory:个人史BirthplaceOccupationsexualhistorysmokingNY出生地职业冶游史吸烟无有aboutyearsaveragepiecesperdayceasedforyears约年平均支/日戒烟年alcoholintakeNoccasionalfrequentaboutyears嗜酒无偶有经常约为年averagemlperdayothers平均ml/日其他Maritalhistory:婚姻史：Marryingagecompanion’sstateofhealth结婚年龄配偶健康状况MenorrheaandChildbearing:月经及生育史Menarcheagecyclelastingfordaysdateoflastperiod初潮每次持续时间末次月经时间(ageofmenopause)绝经年龄Amountofflow:littlenormallargemenstrualpain:NY经量少正常多痛经无有cycle:regularirregularpregnancytimesnaturallabor经期规则不规则妊娠次顺产timesabortionstimesprematuredeliverytimes胎流产胎早产胎stillbirthstimesdifficultlaboranditscondition死产胎难产及病情Famillyhistory(payattentiontothecongenitaldiseasesandcommunicablediseasesandcommunicabledieasesrelatedtothepaitent家族史（注意与患者现病有关的遗传病和传染性疾病）Father:stillaliveillnessdiedcauseofdeathsmother:父：健在患病已故死因母stillaliveillnessdiedcauseofdeathsiblings:others:健在患...
